A. BUILDING S.WING 3576 PIMLICO PARKWAY. ID PREFlX TAe; F OOO! F174. It is the policy of Bluegrass Care anjl

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1 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE &. MEDCAD SERVCES STAtEMENT OF OEFJCENC1ES ANO PLAN 0 NAME O. PROVDER OR SUPPLER (X) PROVlDERSU?PLERlCLlo'. JOENTlFCAT10N NUMBER: BLUEGRASS CARE & REHABLTAlON CENER {X4) ld PR:EF1X SUMf..1ARY STAEMENT OF OE;FCENC1ES (EACH DEFCENCY MUST Be PRECEDED SV FULL REGULATORY LSO DENTFYNG x:l) MULTPLE CONSTRUCTON A. BULDNG S.WNG D PREFlX TAe; STREH ADDRESS. CTY. STATl; lp CODE 3576 PMLCO PARKWAY LEXNGTON KY PROVDER'S Pl.AN OF CCRRECTON EACH CORRECTVE ACTON SHOULD BE CROSS-REFERe:NCED ';'0 THEAPPROpr;AE DEFCENCY) PRNTED:: 07/25/2013 FORM APPROVED OMS NO1l938-D391 (X3) DAft;sURVEY COMet-ETED ont1/2013 ;: jx51 COMPLETON DAn F 000' NTAL COMMENTS F OOO A Standard Recertfcaton Survey and Abbrevated Survey nvestgatng KY#O was ntated on 06/19/12 and concluded on 06/ Defcences were cted wth the hghest Scope and Severty (SS) of an 'EO. KY#O was unsubstantated wth no d efc ences cted. F 174' (k) RGHTTO TELEPHONE ACCESS SS=E : WTH PRVACY F 1741 F174 mmedate Correctve Acton for Resdents Found To Be Affected AB The resdent has the rght to have reasonable access to the use of a telephone where calls can be made wthout beng overheard. Ths REQUREMENT s not met as evdenced by: Based on observaton ntervew and faclty polcy revew t was determned the faclty faled to ensure resdents had the rght to have access to a telephone where calls COUld be made wthout. beng overheard as evdenced by resdents had to use the telephone at the nurse's staton or n a staff person's offce durng regular busness hours. : The fndngs nclude: ; Revew of the faclty's polcy ttled. Telephone ' Resdent Use of dated 06/07 revealed resdents were to have easy access to telephones.. Desgnated telephones were avalable to resdents to make and receve prvate telephone calls. Telephones were to be n areas that offer prvacy and accommodate the hearng mpared and wheelchar bound resdents. t s the polcy of Bluegrass Care anjl Rehabltaton to ensure resdents have the rght to have reasonable access to prvacj whle usng a telephone Resdent A B E and D contnue to resde at the fae lty + Resdent A was notfed that the facltv would be nstallng a cordless phone at each nurses staton for resdent use and the phone would be nstalled on 08/02/2013 per the nstaller. Resdent A expressed bejlg pleased by ths news and agreeable to USe phone at nursng staton untl the cordless phone was nstalled. Resdent B was notfed that the faclty would be nstallng a cordless phone at each nurse s staton for resdent use and the phone would be nstalled on 08/02/2013 p';' the nstaller. Resdent B expressed bellg pleased by ths news. Resdent B.greed ta USe the telephone that was currentlv Nl A- :X::f)2&r13 rch th ('srtf..ltoo may be excused from ectng provdfng \J s delerrrfned tha lher saf>afc1$ provde protecton to the nstructons.) capt for nursng homes) the fndnss staled above are 90 days )lloylf19 lhe das of SUNSY 'N11@t\1efornot a plan of COffeclon s provded. For nursng homes r the above fndngs and plans of correcton are dsclosable 14 ays fol(ovjng the date these doa.jments are made avalable to the faclty. (f defdendes ate an approvedpjan of correcton s requste 10 cdntnued rogram parpcpaton ::')RM CM&-256(OZ.99) prevoj:5. VerslOfl$: Obsolele Factrty D; f oonfnuahon sheet Pag 1 of 29 t l d.'

2 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEME;NT OF DEFCENCES AND PLAN OF CORRECTON NAME 0' PROV'DER OR SUPPLER (Xl) DENTFCATON NUMee;R: 8LUEGRASS CARE & REHABLTATON CENTER (X4) 10 PREFX SUMMARY STATEMENT OF DEFCENCES (EACH OEF1C1ENCY MUST BE PREC OED BY FULL REGULATORY OR L$C DENnFYNG NFORMATON) (X2) MULTPLE CONSTRUCTON A. au1ldlr'\lg B. WNG D PREFX STREET ADDRESS CTY STATE ZP CODe; 3576 PMLCO PARKWAY LEXNGTON KY PROVDER'S P.AN OF CORRECTON CORRECTVE-ACTON SHOULD se CROSS RErERENCED TO THE AFPROPRlATE DERC1ENCY) PRNTED: '07/25/2013 FORM APPROVED OMB NO' ;fj rx3) DATEJS;URVEY Q F 174: Contnued From page 1 ntervew on 07/10/13 at 9:40 AM durng the Group ntervew wth Unsampled Resdent A. revealed the telephone servce at the facmy was J poor. He/She stated he/she had to use the. telephone at the nurse's staton where everyone could hear hs/her conversatons. He/She stated when he/she receved a telephone call someone : would have to come to hs/her room and f he/she was n bed would have to assst hm/her ; up. he/she would have to go to the nurse's ; staton and call the person back. He/She stated he/she would lke to be able to talk n a more t pnva e area. Observaton on 07/10/131 :45 PM revealed a resdent usng the telephone at the North Unt nurse's staton wth staff sttng at the staton and another resdent stmg n a wheelchar n the hallway near the resdent on 111e telephone. Observaton on 07/11/13 at 10:30 AM revealed a resdent usng the telephone at the South Unt nurse's staton wth a staff person Sttng at the staton. : Obse'13ton on 07/11/13 at PM revealed Unsampled Resdent B usng a telepcone n the dnng room near the doorway to the dnng room whch opened ntd the hallway. ntervew on 07111/13 at 4:08 PM wth Unsampled Resdent B revealed there was nowhere prvate to have a telephone conversaton ; n the facty He/She stated he/she had to use the telephone n the dnng room or the nurse's staton. He/She stated f he/sh.. wanted to have a prvate telephone conversaton he/she would have to pay for a cell telephone. Unsampled F 174 avalable for use untl the cordless phone was nstalled on 08/ Resdent b was notfed that the faclty would be nstallng a cordless phone at each rtursels staton for resdent use and the phone would be nstalled on 08/02/2013 per the nstaller. Resdent D expressed beng pleased by hs news ReSdent D agreed to use the telephone that was currently avalable for use untl the cordle.s ph<:me Was nstalled on 08/ Resdent E telephone has been servced add repared. Resdent was also nformed de faclty would be nstallng a cordless for resdent use and lhe phone was nstalled on 08/0:2/2013 per nstaller dentfcaton of Otber Resdents wth Potental to be affected To enhance currently complant operatons under drecton of t)l.e Admnstrator all staff wl receve nservce tranng regardng he federal requrement of F Tag 174 and lhe faclty's polcy. The tranng wll also nclude locatons of accessble telephones where a resdent can be ensured pdvacy as well as the need report a non-functonng telephone '10 the Admnstrator so repars can be completed. Evel'll D: AOTO Faclly 10: f COntnuatDfl sheet Page 2 of 29. j d AdH7 ern? 'c '4 n 'fv Grj(..}j D--V

3 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEM=.NT OF DEFCENC:S AND PLAN 0;:: CORRECTON NAME OF PROVDER OR SUPPLER (Xl) DENTFCATON NUMBER' 6LUEGRASS CARE & REHABLTATON CENTER (X) D pr=.fx SUMMARY STATEMENT DEFCENCES ;EACH DE'::CENCY MUST BE PRECEDE.D BY REGUlATORY OR LSC DENTFYNG NFORMATON) F 1741 Contnued From page 2' Resdent B stated he/she would lke for there to be a cordless telephone for resdents to use SO there would be some way to have prvacy when usng the telephone. ntervew on 07111/13 at 5:07 PM wth Unsampled Resdent E revealed hs/her cell telephone had not been workng for approxmately two (2) weeks. He/She stated he/she had mssed communcatng wth hs/her ' frends: Unsampled Resdent E stated f he/she : was n bed he/she couldn1 get up and go to the telephone at the nurse's staton when hs/har frends called. He/She stated t would be nce f ' there was a cordless telephone for resdents to : use f they ddn't have ther own telephone. The : resdent ndcated he/she Fked to have some : prvacy wth hs/her telephone calls. Unsampled Resdent E stated overall he/she would just lke to : be able to talk to hs/her frends. ntervew on 07/11/13 at 5:16 PM wth Unsampled Resdent D revealed heshe had to go to the nurse's staton to make or receve telephone calls. He/She ndcated t was dffcult for hm/her to get to and from the nurse's staton ' and he/she requred assstance to do ths. : Unsampled Resdent D stated he/she would lke ; to have prvacy wth hs/her telephone cals. He/She stated when he/she had telephone calls : at the nurse's staton he/she felt that others could : hear hs/her conversatons. : ntervew on 07.'11/13 at 4:00 PM wth the Admnstrator revealed she had not been wth the faclty very long. She stated she was. not aware f there were cordless telephones at the North and. Scuth Unts for resdent to use for prvacy wth : :ORM CMS 2S67{0:2-9g) P/ev;OUS Versons ObSOlete Evenl1D:AOTD1 (X2) MULTPLE CONSTRUCTON A. B. V/NG D : F 174' STREE'T AODRESS CY STATE ZP CODE 30ra PMLCO PARKWAY LEXNGTON KY 4Q517 PROVDER'S PLAN OF CORRECTON {EACH COf{RECTVE ACTON SHOULD B:: CROSS.REFERENCED TO THE APPROPRATE DEFCENCY} PRNTED: 07/25/2013 FORM APPROVED OMB Noo (X3) DAT.j';sURVEY COMtLETED All resdents have the potental to be affected by the cted defcency; every. resdent.had ther telephone checked by Socal Servces Mantenance Drector and Assstant Mantenance Drector. These Were checked 7/12/2013 through: 8/] All resdents that had phones had them cheeked to ensure that they were n' workng order. )/0 other resdentr voced concern regardng prvacy accessblty of phones. Measures Taken To Assure There Wll Not. ; Be a Recurrence Cordless Telephones were nstalled on OS for resdents use on both nursng unts. Under the drecton of the Admnstrator telephones wll checked by the Dre-ct6r or the Mantenance Assstant three tmes a week for 90 days then weekly to make sure that they are n workng' order and avalable for resdent use. Socal Serdcts wll comple a lst of resdents that have phones and wth new admts the lst wll be updates. G: 07111/2013 XS) : C:OMr>.ETON DATe Montorng Changes to Assure Contnung; Complance '-..; \ 10: loo4s2 f contnuatlon sheet F'age.3 of 29 9 a

4 1 1 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEME-'T OF DEFCENCES AND OF CORRECT<:lN NAt.tE OF provder OR SUPPLER (Xl) PROVDERSUPPLERCUA NUMBER: BLU EGRASS CARE 8. REHA61L1TATON CENTER 'M'D ' PREFX ' SUMMA'lY STATEMENT OF DEFCENCES «ACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY or LSC DENTFYNG NFORMATON) F 174 COntnued From page 3 ther telephone cals_ The Admnstrator and surveyor observed the North and South UnT nurse's staton where the Admnstrator was unable to locate cordless telephones_ She nqured of the Assstant Drector of Nursng t (ADON) on the North Unt whether there were cordless telephones for resdents to use. The ADON stated there had been cordless telephones before; however they had been removed related ' to poor recepfon_ The Admnstrator stated staff had let resdents use ther offce telephones for : prvacy wth telephones Addtonal ntervew on 07/11/13 at 5:55 PM wth the Admnstrator revealed the faclty staff thought that f they jet '. resdents use ther offce telephones gong out ' and closng the door was gvng them prvacy wth ther telephone cals. F (k)(3)() SERVCES PROVDED MEET SS=E PROFESSONAL STANDARDS The servces provded or arrlnged by the faclty : must meet professonal standards of qualty_ PRNTED:: 07/25/2013 FORM APPROVED OM8 NOJl (X21 CONSTRUCTON (X3) OAfO$URvE' A BULDNG B. WNO cr 07/1;1/2013 D PREFX TAO F 174 STREET ADDRESS CTY STATE. zp CODE 3576 PMUCO PARKWAY LEXNGTON KY To enhance currently complant ; PROVDER'S PLAN OF CORRECTON 'EACH CORRECTVE. ACTQJ SHOULD BE CROSS REFERENCED TO THE APPROPFUATE DEFCNCY operatons under drecton of the Admnstrator all staff wll receve n-servce tranng regardng the federal requrement of F tag 174 and the faclty's polcy. The tranng wll llso nclude locatons of accessble telephones where a resdent can ensure prvacy as well as the need to report a noofunctonng telephone to the Admnstrator so repars can be completed. Receve nservce tranng; 8/2/13 thro Moo3 Date of Completon; 08/ F 281 ' (X51 ;1 OAc Phones where nstall.a on 1. '. :.. '' Ths REQUREMENT s not met as evdenced by: Based on observaton ntervew and record revew t was determ ned the faclty fa'ed to ensure servces provded met professonal standards of qualty as evdenced by the faclty's falure to ensure all Physcan's Orders were ' followed by starr for fve (5) of twenty--one (21) sampled resdents (Resdents #2 #6 tt7 re and #9). : Resdent #-7 had a Physcan's Order for a wound =arm CM$-2567(02 99) Versons Ob$Olele Event D:AOTO Padfuy 10: ' f contnuator'l sheet Page 4 of 29 <. ' Ld LOG9 'ON

5 DEPARTMENT OF HEALTH AND HUMAN SERV CES CENTERS FOR MEDCARE 8. MEDCAD SERVCES STATEMENT DF DEFCENCES AND PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER 1X1) DENTFCATON NUMBER: BLUEGRASS CARE & REHABLTATON CENTER (X4) D : P'<EFX ' SUMJv1ARY STATEMENT OF DEFlClENC1ES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) F 281 ' Contnued From page 4 treatment to hs/her rght lower extremty whch ncluded the use of a foam dressng to cover the wound; however observaton of the wound treatment on /13 revealed the nurse faled to apply the foam dressng durng the treatment. Resdent #9 had a Physcan's Order to place an alarm on the resdent's wheelchar (to alert staff f the resdent tred to get up out of the wheelchar): however observaton revealed staff dd not ensure an alarm was n place. F<esdent #6 had a Physcan's Order for a tube : feed rate of 75 mlllters (ml per hour; however observaton durng survey revealed the tube feed rate was at 70 (ml) per hour. Resdent #8 had a Physcan's Order to contact the surgeon on 07/08/13; however the surgeon was not contacted by staff unt;1 07/10/1:3. (x.) MULTPLE CONSTRUCTON A BULDNG B.WNG D PREFX F 281 PRNTED: 07/25/2013 FORM APPROVED ; OM8 (X3) DATEuRVEY C 07/ STREET ADDrtESS. em' STATE ZP 3S76MLlGO PARKWAY LEXNGTON KY 4Q511 PROVDER'S OF CORRECTON (EACH CORRECTVE ACTON Sff)ULD SE CRosS REFoRENCED TO THE APPROPRATE DEFCENCY) F281 mmedate Correctve Acton for Resdents. Found To Be Affected.. ' t s the polcy of Bluegrass Care and Rehabltaton Center to ensure' that servces provded for each' resdent meet professonal' standards of qualty. Resdent #7 contnues to resde at the faclty. The foam wound' dressng was mmedately apple«and contnues to the ste as ordered' by the physcan. The ARNP and' The Wound Care Physcan j assessed the resdent On 7.111/13.' OATE Resdent #2 had a Physcan's Order to be gotten out of bed for lunch and dnner: however observaton durng survey revea led staff faled to get the resdent out of bed. The fndngs nclude: ntervew wth the Drector of Nursng (DON) on 07/11/13 at 6:00 PM revealed there was no faclty polcy on followng Physcan's Orders but ; her expectaton was staff was to follow PhysCan f Orders. 1. Revew of the medcal record revealed the '' faclty admtted Resdent #7 on 01/30/13 wth dagnoses whch ncluded Muscle Weakness Chronc Arway Obstructon Quadrplega.. Evsor;l O:AOTD11 f contnuaton sheet?-'age 6; of 29 l '. 8l d

6 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMONT OF DEFCENCES ANO PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER (Xl) PROVDER/SUPPLER/CLA DENTFCATON NUMBER: BLUEGRASS CARE & REHABLTATON CENTER (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENFYNG NFORMATON) F 281 Contnued From page 5 Dabetes Type and an Open Wound. Contnued revew of the medcal record revealed ; the resdent was re-admtted by the faclty on 04/01/13 after beng sent out on 03/0$/13 to the hosptal wth an nfected and worsenng rght : lower extremty wound Revew of Resdent #7'5 July 2013 Physcan's Orders revealed a wound treatment order dated : 06/24/13 to apply equal parts of Santy and Bactrob'an to the rght lower extremty wound cover wth a foam dressng and secure wth Kerlx daly and as needed j Observaton of the wound treatment performed on 07/10/13 at 10:50 AM by Lcensed P/ltctcal Nurse (LPN) #3 revealed the LPN appled the : Santyl and Bactroban but dd not cover wth a foam dressng before wrappng the ste wth Kerlx: as ordered. J ntervew wth LPN #3 on 07/10/13 at 12:03 PM revealed she forgot to put the foam dressng on the wound ste pror to securng wth the Kerlx. The LPN stated she should have followed the Physcan's Order (and appled the foam dressng) LPN #3 further stated she was : supposed to follow the treatment order but was dstracted and forgot to put on the foam dressng. Contnued ntervew wth the DON on 07/11/13 at 600 PM revealed the nurse should have ; ; followed the Physcan's treatment order for the : : wound. 12 Revew of the medcal record revealed the faclty admtted Resdent #9 on 01/30/13 wth dagnoses whch ncluded Alzhemer's Dsease X2) MULTPLE CONSTRUCTON A euldng a.wng D Pr<;FX F 281 PRNTED '07/25/2013 FORM\.PPROVED OM8 NO-'J.93S-D391 X3) DATEj\\URVEY COMT-ETED cr 07/1' STREET ADDESS CTY STATE. ZP CODE 3575 PMLGO PARKWAY LEXNGTON KY '\ PROVDER'S PLAN of CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE: APPROPRATE DEFCENCY) OrMrs have been receved and addressed Resdent #9 contnues to resde at the faclty. The resdents alann was replaced mmedately upon knowledge that alarm was not present. Resdent #6 contnues to resde at the faclty. The feedng tube rate was corrected mmedately and contnues as ordered by the physcan The resdent was. assessed by the Nurse Practoner and labs were ordered on July and results called to MD/ARcW. Lab results receved and new orders carned out ReSdent #8 contnues to resde at the faclty. The surgeon was notfed and any addtonal orders for notfcaton have been. addressed Resdent #2 contnues to resde at L the faclty. The resdent was assessed and stated meal locaton preference was n her foom ; Socal Servces dscussed need to be up at meal tme for socalzaton.. and resdent understood consequences of not eatng n a group settng. The faclty wll respect the resdent's rght to choose and wll contact the physcan. :Responsble party was unable to.be.. ached by phone so careplan leller was sent. Careplan.. scheduled for 08/06/20 l3. :x;) -COMPl;;rON OAT: '. =jdjl1y D: 'f CQJ:.nuaton sheet?age e of 29.; 61 G ElOl91 'Eng

7 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF OEF CENCE$ At..JD PLAN OF CORRECTON NAME OF PROVDER OR SUpPLER (Xl) PROVlDERSlJPPLERlCLA 1011FCATON NUMBER: BLUEGRASS CARE & REHABLTATON CENTER :X4) D PREFX. SUMMARY STATEMENT OF OEFCENC1ES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC OENTFYlNG NFORMATON) F 281 Contnued From page 6. Dffculty Walkng Cataract and Muscle : Weakness Revew of the Quarterly Mnmum Data Set (MDS) Assessment dated 04/30/13 revealed the faclty assessed the resdent wth moderate cogntve mparment Contnued revew of the MDS revealed the faclty had assessed the resdent as needng extensve assst of one (1) staff person for transfers. Revew or Resdent #9's care plans revealed the faclty eare planned the resdent as havng the potental for falls oated July 2013 due to decreased physcal and cogntve functon decreased vson and a dagnoss of Alzhemer's Dsease. ' (X2) MUTPco CONSTRUCTON A. BULDNG S.WlNG D PREFX rag F 281 STREET ADDRESS. CTY. STATE. ZP CODE 3576 PMl.lCO PARKWAY LEXNGTON KY PROVDER'S plan OF CORRECTON CORRECTVE ACTON SHOULD BE TO THE APPROPRATE DEFCENCY) PRNTED:' 01/25/2013 FORM APPROVED OMS NO:o (XJ) CQ\/?LETED <t 07/$ [XS) :' COMP.ETON :1 DATa..;aRM CMS-2567(02-99j Revew of Resdent #9 1 $ PhyScan's Orders for : : July 2013 revealed an oroer orgnaly dated 03114/12 to place a pressure sensor alarm to the; : resdent's char to alert staff of unsafe transfers Revew of the Treatment Admnstraton Record (TAR) for July 2013 revealed staff was checkng to see f the char alarm was n place once da:y. However observatons when Resdent #9 was n hs/her wheelchar on 07/09/13 at 3:24 PM and.4:01 PM and on 07/10/13 at 10:30 AM 11 :56 AM ; and 2:23 PM revealed no pressure alarm was ; attached to the wheelchar ntervew on 07/10/13 at 2:23 PM wth Certfed Nursng Assstant (CNA) #4 who verfed '1 : Resdent #9 had no alarm attached to hs/her wheelchar revealed the resdent was supposed to have a pressure alarm devce. The CNA #4 stated the resdent removed the alarm and staff ; tred to check to make sure the alarm was n place.. :S Verslal'\.S Oosalele ' Faclt'jlD: 10C492. ' ;. : tt contnlzlon sheet Page 7 of 29 l l' OGd

8 1 3. DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES ANa LAN OF CORRECTON NAME OF PRCVDE1X OR SUPPLER (Xl) PROVDERSUPPLlERfCLA DENTFCATON NUMBER: BLUEGRASS CARE & REHABLTATON CENTER (X4) D prefx SUMMARY STATEMENT OF DEFCENCES ;EACH DECENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) ;X2) MUL CONSTRUCTON A. B. WNG D STREET ADDRESS CTY STATE ZP CODE PMLCO PARKWAY LEXNGTON KY PROVDER'S PLAN OF CORRECTON (EACH CORRECTV ACT'ON SHOULD BE CROSS REFERENCED Yo THE APPROPRATE DEFCENCY; PRNTED: 07/25/2013 FORM APPROVED OMB NO 093$ 0391 (X3) DATE:;URVEY COMt>LETED -.)... 07/1.1/2013 < '. (X5) 'COMF'lJON ClATe: F 281 : Contnued From page 7 ntervew. on 07/10/13 at 2:39 PM wth Nurse (RN) #2 revealed she dd not see an alarm on Resdent #9's wheelchar as : ordered. The RN stated there should have been an alarm on the wheelchar. RN #2 further stated she was unaware the resdent removed the alarm : and should have been nformed. ' ntervew wth lcensed Practcal Nurse (LPN) : t7staffng Coordnator on 07/11/13 at 12:50 PM. revealed the resdent had a Physcan's order for a char alarm and when she checked the ; wheelchar on 07/10/13 at 7:15 AM the alarm was n place. When nformed observatons revealed ' : the alarm was not attached to the resdents : wheelchar the LPN stated the resdent had a hstory of removng the alarm and hdng t. LPN : ; #7 further stated they needed to educate staff to check the alarm durng any care nterventons wth the resdent. She stated f the alarm was not ; n place staff dd not follow the orders. Contnued ntervew wrth the DON on 07/11/13 at 6:00 PM revealed the pressure alarm should. have been attached to the wheelchar as ordered by the Physdan Revew of the medcal record revealed the faclty admtted Resdent #$ on 01/16/13 wth : dagnoss of Acute Delrum Functonal Declne wth recent fall advanced Alzhemer's Dementa hypemenson dehydraton and Rght CVA wth Left hemparess. Further revew olthe medcal record revealed Resdent #6 was readmtted on 04/24/13 after peg tube placement. Record revew of facl1y's polcy and procedure F 2$1' ; c..' ;. : EvenlO:AO'TD11 D: f contnuaton sheet Page S of 29. Go

9 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEME OF DEFCENCES X'll PROV:DERSUPPLEpJCLlA AND P.AN OF CORRECTON DENFCAON NUMBER; NAME OF PROVDER OR SUP'PLER BLUEGRASS CARE 8. REHABLTATON CENTER (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED By FULL REGULATORY OR LSC DENTFyNG ttled Nasogastrc/Gastrostomy Tube Feedngs wth an Effectve Date of 12/2012 revealed under. procedure for checkng placement of tube feedng pror to feedng on page two follow the amount. F 281 Contnued From page 8 of formula rate and hours Of admrstraton ordered by Physcan. 1 ReCord revew of the Physcan's Orders dated 07/03/13 at 3:55 PM revealed the Detltars' : reccmf1)endaton to advance the tube feedng ; rate to 75 ml/hr of Jevty 15 x 16 hours wth 30 ml of Pramod per g-tube daly ' ) (X2) MULTPLE CONSTRUCTON A BULDNG 8. WNG D prefx STREET ADDR:SS crry. STATE ZP CODE 3576 PMLCO PARKWAY lexngton KY F281 ; PRNTED; 07125/201 S FORMft..PPROVED OMS N0:1;) X3) DAT>URVEY PROVDER1S plan OF CORRECTON ' XS) EACH ACTON SHOULD CROSS-REFERENCED TO THE APPROPRATE OEFCENCYj : d : CDM?l=r:ON.' DATE :. Record revew of the Medcaton Admnstraton ; Record (MAR) wth a generaton date of 06/27/13 revealed dscontnuaton of order for Jevty 15 at a rate of 70 ml/hr x 16 hours (off 6:00 AM to 2:00 PM) dated of 07/03/13 Record revew 0: the MAR 07/03/13 revealeld Jevty mllhr x 16 hours (off 6:00 AM to 12:00 PM) had been sgned and dated snce 07/ Observaton on 07/09/13 at 3:07 PM tube feedng rate 70 mlhr of Jevty 1 S closed system wth date 0107/09/13 and tmed at 2:00 PM j Observaton on 07/09/13 at 4:05 PM tube feedng rate 70 mllhr of Jevty 1.5 closed system wth date of 07/09/13 and tmed at 2:00 PM. Observaton on 07109/13 at 5:25 PM tube feedng rate 70 mvhr of Jevty 15 closed system wth date of 07/09/13 and tmed at 2:00 PM ntervew on 07/10/13 9:40AM wth the Regstered Dettan revealed Resdent #6 should ORM Cv1S-2S67{02 99) PreVOUS Versons Eve-nD:AOT011 f contnua:orr sheet Pase e of 29 l <

10 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES ANO PLAN OF CORRECTON NAME OF PROVDER Ol': SUPPLER :Xl) PROVDERfSUPPLlERJCLA DENlFCATON BLUEGRASS CARE & REHABLTATON CENTER {X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH MUST BE PRECED'D BY FULL REGUl..ATORY OR LSC DENTFYNG NFORMATON) F 281 Contnued From page 9 be on Jevty 1.5 at 75 ml/hr She also revealed she had not been nformed of any problems wth tolerance to the tube feedng at the new rate. nterv;ew on 07/10/13 at 9:50 AM wth RN #1 revealed the MAR's current order for ReSdent #6's tube feedng had been advanced to 75 mlhr of Jevty 15 and further revealed he/she was : toleratng the tube foodng. ntervew by phone on 07/11/13 at 3:25 PM wth LPN #6 revealed she was assgned Resdent #6 ; on 07/08/13 and 07/09/13. She revealed she receved shft report pror to startng her shft and nformaton was also located on the MAR. She further revealed she receved report that Resdent #6 was ordered tube feedng at 70 mllhr but could not remember for sure f there had been any changes to the PhysCan's orders whch were ; usually flagged n the chart and a 24 hour sheet was used to record nformaton for shft change and was not aware of any order change for Resdent #6. ntervew wth the DON on 07/11/13 at 6:00 PM revealed her expectatjon of staff vver : to follow Physcan's Orders. 4. Record revew revealed the faclty admtted : Resdent #6 on 07/01/13 wth dagnoses whch ncluded recent below the Left Knee Amputaton Perpheral Vaswlar Dsease Osteomyelts End Stage Renal Dsease Dabetes and receved dalyss. Revew of the Nurse's Notes for Resdent #8 dated 07/07/13 at 7:55 PM revealed the on-call surgeon gave a telephone Physcan's Order for E'/erY 10: AOTO 1 (X2) MULTPLE CONSTRUCTON A. BULDNG SWNG D PREFX STREET ADDRESS CTY STATE ZP CODE PRNTED: 07/25/2013 FORMWPROVED OMS NOhfj (X3) DATEJURVEY 3576 PMLCO PARKWAY LEXNGTON KY PROVDER'S PLAN OF CORRECTON leach CORRECTVE ACTON SHOULD BE CROSS'REFERBlCErnO THE APPROPRATe ' DEfClENCV)c F 281 dentflcatlon of Other Resdents wth the potental to be affected All Resdents have the potental to be' affected by the cted defcency 100% of all resdent orders Were revewed by Assstant Drector of Nursng (ADON) Unt Manager (UM) Mnmum Data Set Coordnator's (MDS) Wound Care Nurse (WCC) Staff Development Coordnator (SOC) Drector of Nursng (DON). Care plans were updated to ret1ect the orders. ahd SR.\lA care plans revewed for accuracy The DON (Drector Nursng) ADON (Assstance Drectof of Nursng) wll fonnulate lst of resdents wth a dressng alarms tube feedngs and 'Pecal nstnctons MeasureS Taken To Assure There Wll NJ Be a Recurrence.j Cl.1 \X51 : '::OMF'LCTON : DATE MD orders wll be revewed and compared to the medcaton recof (MAR) and treatment record (TAR) ly the Assstant Drector of Nursng (ADON) Unt Manager (UM) Drector of Nursng (DON) Staff Development Coordnator (SOC) Wound Care Nurse (WCC) and. Mnmum Data Set Coordnators' (MDS). To enhance currently complant operatons under the drecton of the DON (Drector of Nursng) alllcense' staff and SR.\lA's wll receve m-;' serl'ce tranng on F Tag 281 wth ar Facj11ly D: f corlllnvaloslo.et. 10 of 29 f. G d

11 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER {Xl) PROVDEFVSUPPl=-R'CLA DENTFCATON NUMBER: BLUEGRASS CARE & REHABLTATON CENTER P<'4) D PREFX SUMMARY STATEMENT OF DEFCENCES DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENT'YNG NFORMATON) F 281 Contnued From page 10. staff at the faclty to contact the resdenfs [ prmary surgeon on the mornng of 07/08/13. Further revew of the Nurse's Notes revealed no documented evdence of the ccmpleton of the. order to contacted the prmary surgeon On 07108/13. j (X2) CONSTRUCTON :X3) A. BULDNG S.WNG D PREFX F 281 ADDRESS CrTY STATE ZP COOE 3576 PMLCO PARKWAY LEXNGTON KY PROVDER'S PlAN OF CORRECTON EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPt{OPRATE DFCENCY).. : PR NTEO; 07/ FORM APPROVED OMB emphass on dressng changes alanns tube feedng settngs physcan ' notfcaton and resdenrs needng to be out of bed n-servce trall:n2 ntated. onll1/2013 through 8'1/2013 G 07/1;1/2013. (XS ' C OMP... ;;-f ON :1 CATE. r t ntervew wth Prmary Surgeon's offce nurse on :. 07/10/13 at 11 :25 AM revea led as far as she was able to determne no phone call was receved from the faclty regardng Resdent #8 The Nurse stated no dooumentaton of conversatons ṭ whch should have been n the resdenfs chart f the faclty had called to dscuss ths resdent. : ntervew wth Assstant Drector of Nursng : (AD ON) on 07/10/13 at 2:40 PM revealed there should have been dogumentaton n Resdent #8's chart f the cal was made to the prmary : surgeon's offce Further ntervew wth ADON on 07111/13 at 09:30 AM revealed the faclty should had contacted the prmary surgeon's offce ' accordng to the Physcan's order n the chart on ' t 5. Revew of the medcal record for Resdent #2- revealed the faclty admtted the resdent on 07/20/12 wth dagnoses whch ncluded a hstoly of Cardovascular Accdent wth Hemplega ' Dffculty Walkng and Alzhemer's Dementa. Revew of the Quarterly Mnmum Data Set (MDS) Assessment dated 03l2613 revealed the faclty assessed Resdent #2 wth a Bref ntervew for Mental Status (BMS) score of eleven (11) out of ffteen (15) whch ndcated the : resdent was moderately mpared cogntvely. Further revew of the MDS revealed the faclty..:..... assessed Resdent #2 to requre extensve assst. of one (1) to two (2) staff for hs/her Actvtes of Evem D:AOTDll FlClty 10: t contllllaflon sheet Page 11 of :9 >l? '. LOG9 N

12 DEPARTMENT OF HEALH AND HUMAN SERvCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLA-l OF CORRECTON NAME OF PROVDER OR SUPPLER (Xl) PROVDER)SUPPLERCLA. DeNTFCAnON NUMB' BLUEGRASS CARE & REHABLTATON CENER ; (X4) D SUMtv\ARY STATE:M:1\l OF OEFCENCES (EACH DEFCENCY MUST BE preceded BY FULL REGULATORY OR lsc DENTFYNG NFORMATON) F 281 Contnued F rdm page 11 Daly Lvng (ADLs) ; Revew of the July 2013 monthly Physcan's ; Order revealed an order for Resdent #2 to be up n a char and to the dnng room for meals at least lunch and dnner. ; Revew of the July 2013 State Regstered Nursng Asslst<lnt (SRNA) Care Plan Record revealed no documented evdence of the Physcan's Order for ReSdent #2 to be up n a char and to the ' dnng room for meals at least lunch and dnner ; Observatons on 07/09/13 at 4:30 PM 5:15 PM 5:37 PM and 6;06 PM revealed Resdent #2 to be lyng n bed Observaton revealed Resdent ; : #2 receved hs/her dnner meal tray at 6:06 PM. Observaton on 07/1 0/13 at 8;05 AM revealed Resdent #2 to be lyng n bed wth the head of the bed elevated wth hslher breakfast meal tray n front of hm/her on the overbed table Observaton on 07/10/13 at 4:50 PM revealed Resdent #2 to be lyng on the bed wth hslher [ eyes' closed. ntervew on 07/11113 at 2:25 PM wth CNA #7 revealed she WaS assgned to work on Resdent #2's hall that day. She stated she had never ; gotten Resdent #2 up for meals snce she had been workng at the faclty. CNA #7 stated she had been employed for approxmately two (2) months She stated she was not aware of an larder for Resdent #2 to be up and to the dnng room for meals. CNA #7 revewed the CNA Care Plan ReCOrd and stated there was no nformaton related to the order for Resdent #2 to be up out of bed and to the dnng room for meals PRNTED: m;25/2013 FORM APPROVED OMB N01l (;<2) MULTPLE CONSTRUCTON 1X3) A6ULDNG COMll-ETEO awn<;; F281 ' STREET CTY. STATE. ZP CODE 3576 PMeleo PARKWAY LEXNGTON KY provder's PLAN OF CORRECTON {:'ACH CORRECTVEAcnON SHOULD BE CROSSREFERENCED TO THE APPROPRLo.TE DEFCENCY).. Montorng 8Ja.-nges to' Assure Contnung Complance q 07/W2013 A Qualty Assurance program was: mplemented under the supervson of the Drector of Nursng to molltor pressure sore preventon of resdents recevng OX)lgen va nasal cannula and tubng Current:. resdents Were dentfed and a lst compled. New resdents wll be added to the lst durng revew of; physcan orders n the mornng Clncal meetng The resdents wll be montored 3 tmes weeklv' for 4 weeks. Weekly for 4 weeks. ' And then monthly ongong: MOlltorng results wll be brought.: to the monthly Qualty Assurance: meetng for further revew;. analyss l correctve acton and recommendaton as needed The commttee wll revew monthly. and follow up untl at such consstent substantal complance' has been acheved as detennned by the commttee The Qualty Assurance Commttee (Consstng of a blend of the Medcal Drector Admnstrator Drector of Nursng Assstant Drector of Nursng l Mnmum Data Set\ XS). '-COMPl.ETON EvenD:AorO\ f cont;'lual;or. sheet Page of 29 LOG9 'ON r O' 7 ;:; f L

13 '' DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PlAN OF CORRECTON NAME OF PROVDER OR SUPLlER X') PROVOER/SUPPLER/CLA DENtFCATON NUMBER: BLUEGRASS CARE & ReHABLTATON center (MlO PREFX' ; SUMMAR.Y STATEMENT OF OEFCENCES (each OEFCENCY MUST Ba PRECEDED BY FULL REGUlATORY LSC OENTtFYNG NFORf\1ATONj F 281 Contnued From page 12 ntervew on 07111/13 at 2:43 PM wth CNA #5 : revealed he had cared for Resdent #2; however : was unaware of an order for hm/her to be up and to the dnng room for meals at least lunch and dnner. ' ntervew on 07/11/13 at 2:30 PM wth LPN #4 revealed Resdent #2 sometmes got up for ; meals: however the resdent refused a lot LPN' #4 stated she was aware of the Physcan's Order for the resdent to be up and to the dnng room fer meals at least lunch and dnner. She stated she had not documented Resdent #2's refusals to get up; however should have. 'ntervew on 07/11/13at2:55 PM wth the North Unt Assstant Drector of Nursng (AOON) revealed she thought the Physcan's Order for Resdent #2 to be up and to the dnng room for meals was on the SRNA care Plan ReCOrd so the CNA's knew to try and get the resdent up for : meals TheADON revewed thejuly2013 SRNA ' : Care Plal1 Record and stated she could not nod the nformaton located on t. The AOON ndcated Resdent #2 refused at tmes and stated ths should be documented She stated the PhYScan's Order should be followed and any refusals documented F 314 4S3.25(c) TREATMENT/SVCS TO PREVENTHEAL PRESSURE SORES Based on the comprehensve assessment of a resdent the faclty must ensure that a resdent who enters the faclty wthout pressure sores does not develop pressure sores unless the ' ndvdual's clncal condton demonstrates that they were unavodable; and a resdent havng pressure soes receves necessary treatment and X2) MULTPt.E CONSTRUCTON A SULONG S.WNG 10 PReFX F 281 STREET AOOR.E.S$ CTY STATE Zp CODE 3576 PMLCO PARKWAY LEXNGTON KY PROVDER.'s PLAN OF CORRECTON (EACH CORRECTlVEACTON SHOULD 6E CROSS REFERENCEO TO THE APPROPRATE OEFCENCY) PRNTEO: 07/25/2013 FORM APPROVEO OMB NO G938-D391 (X3) OUEpVEY C/ }2013 Nurse Wound Care Nurse Human Resource Drector Detary M:u:ager Rehab Sen ce Manager BUSness Offce 1fanager Actvtes Drector Admssons Drector Socal Servce Drector Plant Operatons Drector' Envronmental Servce Drector Pharmacy Servce. Lab Servce Manager Medca Records Drector Staff Development Coordnator and the Chaplan) Completon Date: 8/15/2013 '. : XS) OOMFtElQN DAT: OR.M CMS2567(02-99) PreYOl.lS Vers:ons Ob:SQlale EvenO:AOT011 10: f contfl(..laton sheet Page 13 of 29 -;.

14 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF OEFCENCES AND PLAN OF x) PROVOER/SUPPlERJClA 10ENTFCATON NUMeEF1: (X2) MULTPLE CONSTRUCTON A. SUlLO NC BWNG PRNTED: '07125/2013 FORM APPROVED OMB NO:G (X3) ONE)llURVEY COMllLErEO d NAME OF PROVDeR OR SUPPLER BLUEGRASS CARE & REHABLTATON CENTER STREET ADDRESS CTY. STATE. ZP COOE 3576 PMLCO PAAKWAY LEXNGTON KY ;X4) 10 PREFX SUMMARY STATEMENT OF DEFClENClfS (EACH OEFCENCY MUST BE preceoeo BY FUl.L REGULAORY OR lsc OENTFYlNG NFOR.t\.1ATON; 10 PR.EFX j PROVDER'S PLAN OF CORRECTON 'EACH CORRECTVE ACTON SHOVLO BE CROSS-REFERENCeD TO THE APPROPRATE OEFCENCY) ': : COMPLETON ' DArE F 314 Contnued From page 13 servces to promote healng prevent nfecton and: prevent new sores from developng. '; ; Ths REQUREMENT s not met as evdenced. by: Based on observaton ntervew record revew and revew of the faclty's polcy t was determned the faclty faled to ensure resdents : who entered the faclty wthout pressure sores dd not develop pressure seres for one (1) of menty-one (21) sampled resdents (ReSdent 6). Observaton durng a skn assessment revealed Resdent ffl had oxygen (02) tubng pulled rghtly' across hs/her face and ears. The skn assessment revealed the resdent to have open : areas at the top of each ear whch were assessed to be Stage pressure sores. [ The fndngs nclude: The faclty dd not provde a polcy specfc to ; : pressure sore preventon. Revew of the polcy ttled Skn Management and Preventon At.A-Glance' undated revealed Certfed Nursng Assstants (CNA's) were to complete a total body : skn observaton durng CNA's were to observe the esdent's skn durng routne care. Any concerns Were to be documented on a : Skn Alert Sheet and fndngs reported to the. charge nurse. ; Revew of Resdent ffl's medcal record revealed an admsson date of 01/16/13 and a readmsson. date of 04/24113 wth dagnoses wh ch ncluded Alzhemer's Dementa ChronC Obstructve Pulmonary Dsorder (COPD) and Stage V : Pressure Sore on the left medal and lateral foot. F314 mmedate Correctve Acton For Resdents Found To Be Affected. S ;.: t s the polcy of Bluegrass alld Rehabltaton Center O ensute pressure sore preventon and provde necessary treatment and servces to promote healng and preventons. Resdent #6 contnues to resde at the faclty. Treatment orders were' obtaned for the pressure area both ears. Areas behnd both ear;' are resolved as of 7/22/ ORt. CMS-2SQ1(02-Q9) Prevous Ver::;om. ObsQlel1S Evenl O:AOTO1 Faclhy 10: 10C4Q2 t contnuaton sheet P;;ge 14 of 29.. '.

15 DEPARTMENT OF HEALTH AND HUMAN SERVCES centers FOR MEDCARE & MEDCAD SERVCES STATEMENT OF OEFCENCES ANO P1..AN OF CORRECTON (Xl DENTFCATON NUMBER: (XZ: fl..ultlple CONSTRUCTON A. BULONG B.WNG PRNTED:' 07: FORM /'.PPROVED OMS NO;' l (X3) cml-eteo & NAME OF PROVDER SUPPLlr=R BLUEGRASS CARE & REHABLTATON CENTER (X4) [) PREX ; SUMWARY STATEMEf.T OF DeFCENCES (E ACH DEFCENCY MUST 6E PRECEOEO BY FULL REGU..ATORY OR LSC DENTFYNG NFORMATON) F 314. Contnued From page 14 Revew of the Annual Mnmum Dala Set (MDS) : Assessment dated 05102/13 revealed the faclty assessed Resdent:16 to be moderately mpared cogntvely and requred extensve assst to tolal : dependence on Slafffor Actvtes of Daly lvng. ' : Further revew of the MOS revealed the faclty assessed Resdent #(j to be at rsk for pressure sores. 10 PREFX F 314 STREET AOORES$ cty. STATE ZP CODE 3576 PMLCO PARKWAY LEXNGTON KY ' PROVDER'S PLAN OF CORRECTON ('''CH CORRECTVE ACTON SHOULD BE CROS$ RE'ERENCED TO THE APPROPRATE DEF C.NCY dentfcaton of Other Resdents wth the Potent.l to be affected All resdents had a complete head to' toe skn assessment porformed to determne f any undentfed skn. mparments were present. Audt was; completed On 08/05/2013 wth no other areas dentfed.. Revew of the Comprehensve Plan of Care. updated revealed Resdent #6 was at rsk for skn breakdown related to dagnoses of Alzhemer's Dementa and hstory of Cardovascular Accdent. nterventons ncluded to observe skn durng personal care. Revew of the Potental for neffectve Breathng Pattern Plan of Care dated 07/13 revealed Resdent #6 requred the use of oxygen (02). Revew of the nterventons ncluded no documented evdence to montor the 02 nasal cannula tubng to ensure Resdent #6 dd not develop pressure sores from t Revew of the Weekly Skn Rounds form dated /13 revealed no documented evdence Resdent #6 had open areas over hs/her ears. Revew of the Nurse's Notes revealed no : docum ented evdence of open areas over ' Resdent #6's ears where the 02 nasal cannula tubng rested...' Revew of the July 2013 monthly Physcan's Orders revealed an order for Resdent #6 to have oxygen (02) at two (2) lters per mnute per nasal cannula. Observaton on ;13 at 3:30 PM of Resdent :16's head to toe skn assessment performed by ORM CMS-2567(02-99) PrevlQUS VersJO1$ Obsole\e ; All resdents have rhe potental to be affected by rhe cted defcencj\ ncludng resdents wearng oxygell: wth nasal tubng the DON developed a lst of resdepts recevng Oxygen: admnstraton USng a nasal cannuht': and tubng to be checked for potenta' skn breakdown. Any new resdent orders for Oxygen admnstraton usng a nasal cannula and tubng wll be: revewed durng the mornng ClncaJ.' meetng and added to the montorng lst.. Measures Taken To Assure There Wll Not Be a Recurrence To enhance currently compladt operatons under rhe supervson of the DON all staff was n-servced On 314 wth emphass on observng resdents weanng oxygen nasal cannulas and tubng and the tubng beng pulled to rghtly. Also lcensed staff and SRNA' s were n servced ol rhe faclty polcy on pressure sore preventon and observng and' communcatng nformaton correctly_:' lnservced 7/11/2013 to 8/2/2013.) f contnuaton sheet 15 of 29 ;.

16 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF OEFCENCES ANa Pt.AN OF CORRECTON NAME OF PROVloeR. OFt SUPPLER :X1 PROVOERlSUPPLERlCllA DENTFCATON BLUEGRASS CARE & REHABLTATON CENTER (M) 10 SuMMARY STATEMEN OF OEFCENCES (EACH OEFCENCY MUST BE PRECEOoO BY FULL REGULATORY OR LSC 10ENntYNG NFORMATON) PRNTED: '07/ FORM APPROVED OMB NO X2) MULTPlE CONS7RUCTON (X3: DATEuRVEY A. BULONG COMPt:ETEO B.WNG 10. PREFX C 0711'1/2013 STR.EET AOORESS cty STATe ZP COO: 3576 PMLCO PARKWAY LEXNGTON KY \ PLAN OF. leach CORRECTVE ACTON SHOULD BE CROSS REFERENCEO TO THE APPROPRATe DEFCENCY) : 'XS' : CAG; F 314 : Contnued From page 15 Lcensed Practcal Nurse (LPN) #2 revealed Resdent #6 to have 02 nasal cannula tubng to be pulled tghtly across the resdenfs face and : over hs/her ears. Durng the skn assessment the LPN removed the 02 nasal cannula tubng from over Resdent #6's ears. Observaton revealed Resdent #6 to have open areas over hs/her blateral ears. ntervew on 07/10/13 a 3:30 PM durng the head to' skn assessment wth LPN #2 revealed. she was not aware of Resdent #6 havng open : areas over hs/her blateral ears. She stated she thought the open areas were Stage pressure : sores. ntervew on 07/10/13 at 3:53 PM wth the. Advanced Regstered Nurse Practtoner (APRN) ; revealed she should be notfed of any change n a resdenfs status $0 approprate treatment could be ordered.. f ntervew on 07/10/13 at 4:13 PM wth Regstered Nurse (RN) #1 who was the Charge Nurse revealed she was no aware of open.w'as j : over Resdent #6's blateral ears. She stated she thought the areas should have been observed durng the resdent's routne care. by the Certfed Nursng Assstants (CNA's).. ntervew on 07/10/13 at 4:16 PM wth CNA #1 revealed he was assgned to care for Resdent : #6. He stated he was not aware Resdent #6's. 02 nasal cannula tubng was pulled tght. CNA #1 slated he was not aware the resdent had : open areas over hslher blateral ears. Montorng Changes to Assure Contnung Complance All resdetlts wll have a head to toe skn assessment performed at least weekly by nursng to dentfy any skn mparments. The skn assessments wll be revewed daly fve tmes a week r clncal meetng any areas dentfed wll be addressed mmedately. The resdents wll be montored by the DON/ ADON three tmes weekly fof four weeks weekly for four wee.ks arul 1 then monthly ongong. defcences wll be corrected mmedately. A Qualty Assurance program was mplemented under the supervson of.' the Drector of Nursng to montor ' pressure sore preventon of resdents -. recevng Oxygen va nasal carm.ula and tubng.. Current resdents were dentfed and a lst compled new resdents wll be added to the lst durng physcan order revew n he mornng Clncal meetng. The resdents wll be montored three tmes. weekly for four week weekly for four Weeks and monthly ongong. Montorng results wll be brought to the monrhly Qualty Assurance meetng for further revew analyss correctve \ acton and recommendatons as needed. Further revew of the record revealed a Wound Completon Date: 8115/2013 ORM CM$.2S67(02-99j P(eVOUS Ye.'SO'1$ Eve-nlO:AOTDjj Faclly 10: 1C0492 f contlnuaton sheet Page 16 of 29 '.. r:' 07 '9 j v f vlr

17 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMeNT OF oef CENCES ANO PLAN OF CORRECTON NAME OF PROVlOER OR SU??LlER (Xl) PROVOERSUPPURlCLA DENTFCATON NUMBER: BLUEGRASS CARE & REHABLTATON CENTER 'X') 10 PREFX SUMMARY STATOMENT OF OEFCENCS (each O=FC'ENCY MUST BE PRECEDEO BY FULL REGULATORY OR LSC 10ENTFYNG NFORMATON) (X2) MULTPLE CONSTRUCTON A B.WNG 10 PREFX AOORES$ CY STATE ZP COOE 3576 PMUCO PARKWAY LEXNGTON KY PROVDER'S PlAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE TO THE APPROPRATE:: DEFCENCy) PRNTED: 07/25:2013 FORM APPROVED OMB NO (X3) DATE COMP;;TEO C l 07/ : X.:l C Ml.ErON DATS ' F 314 Contnued From page 16 Care Specalst Physcan's Note dated 07/11/13 whch revealed ReSdent #6 had Stage pressure sores over hslher blateral ears whch : were due to 02 tubng ntervew on 07111/13 at 6:00 PM wth the Drector of NUrsng (DON) revealed she would expect the CNA's to observe resdents' ear area when they were washng ther faces She stated staff was traned to observe res dents' skn F 371 ; () FOOD PROCURE Ss-.E STORE/PREPARE/SERVE SANTARY The faclty must. : (1) Procure food from sources approved Or consdered satsfactory by Federal Stae or local authortes; and (2) Store prepare dstrbute and serve food under santary condtons Ths REQU REMENT s not met as evdenced : by: 8ased on observaton. ntervew and revew of the faclty's polcy 't was determned the faclty faled to prepare dstrbue and serve food under santary condtons as evdenced by three (3) detary staff not followng proper hand washng ' technques by turnng off the faucets wth washed wet hands and dred ther hands wth a paper towel. The Fndngs nclude: Revew of the faclty's detary polcy and O:AOTQ11 F 371 F371 mmedate Correctve Acton for Resdents Found To Be Mfected t s the Polcy of the Bluegrass Care and Rehabltaton Center to store prepare dstrbute and serve : food under santary condtons. dentfcaton of Other Resdents Wth the Potental to be affected rscllty ld: All resdents have the potental to be affected by the cted defcency.. All sraff was nsenced on proper hand washng by Staff ' Development Coordnator Assjstant Drector of >Jursng Drector of )ursng Envronmental Drector Detary' Manager Wound Care on 07/11/2013 to : f contf)(.aton sheet Page 17 of 29. t.; Jo '' r d

18 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATElvlENT OF OE::FCENCES AND P.AN OF CORRECTON NAME OF PROVOER OR SUPP.ER (X1) PROVOER/SUPPLER/CLA QENTFCATON NUMBER; BLUEGRASS CARE & REHABLTATON CENTER (X4) 10 PREFX SU.1MARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRCCEOEO BY FULL REGUlATORY OR. LSC NFORMATON: (Xl) MUL nple CONSTRUCTON A. W.ONG S.WNG 10 PREFX PRNTED: FORM AF)PROVED OMS NO. (X3) COMPl. feo c 07/ STREET AOORfSS CTY STAT; ZP CODE 3576 PML.CO PARKWAY L.EXNGTON KY PROVOER'S PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS_REFERENCED TO THE APPROPRATE OEF C ENCY) (xs) CDMPtE.ON : DA. F 371 Contnued From page 17 procedure ttled Hand Washng effectve date: December 2010 revealed the procedural steps to wash hands. Accordng to the polcy staff s to follow procedural steps when they wash ther hands. The procedural steps ncluded step #fj to dry hands wth dsposable towel and step #7 usng towel turn off faucet Don't touch the faucet wth bare hands Revew of the detaty n-servce sheet dated. 05/29/13.06/09/13 revealed detaty staff educated on food handlng-washng hands between glove use and glove change and hand washng between each food prep_. Observaton n the ktchen durng the lunch meal. On 07109/13 at 12:15 PM revealed three (3) detaty staff usng mproper hand washng technque by turnng off faucets wth bare washed. hands and used paper towels to dry ther hands.. Observaton on at 12:17 PM revealed Detary Ade #9 wth mproper hand washng technque by turnng off faucets wth washed bare. hands and dryng hands wth a paper towel. Observaton on at 12:20 PM revealed PM Cook #8 wth mproper hand washng technque by turnng off faucets wth washed bare: hands and dryng hands 4th a paper towel. 1 Observaton on 07109/13 at 12:25 PM revealed AM Cook #7 wth mproper hand washng technque by turnng off faucets v.ofth washed bare hands and dryng hands wth a paper towel. : Observaton on 07109/13 at 4:40 PM and agan at 4:45 PM revealed Detaty Ade #9 wth mproper F 371 To enhance currently complant operatons under me drecton of. the De-.. Manger all Detarv staff wa; n servced 07/l12013 tlull 08/ on the procedural steps of hand washmg wth emphass on usng a ; paper towel to rum off the Water faucet A rerum demonstraton was requred of all detary staff: Measures Taken To Assure There Wll Not Be a Recurrence :. Because all resdents have the_ potental to be affected by rhe Cted;.. defcency a montorng tool was developed to observe all staff wth emphass on d.my staff durng meal preparaton. The Detary' manager wll montor hand. washng every meal three daly for 5 days then three tmes weekly for four weeks weekly for four weeks and then randomly; every monrh on gong. All staff wll be montored three tmes a ' ;eek tmes four Weeks weekly tunes. four weeks then monthly on-gomg. Any defc ences wll be addressed..' t:vent D;Aor011 FaClty 10: lo:c492 f contnuaton sheet Page 18 Of 29 '... E d